Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221544 Renewal 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)Fire Extinguisher locate in kitchen was under charged and no longer in the green section on the gauge.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The fire extinguisher was serviced on 3/28/23, and the gauge is now pointed in the green section. Please see attachment. 03/28/2023 Implemented
6400.112(e)The location had no asleep drills during sleeping hours at least every 6 months for the entire year of 2022.A fire drill shall be held during sleeping hours at least every 6 months. A new fire drill was conducted on 3/22/23 at 12:30AM. Both administrative staff and homes manager have created an alternating schedule to guide direct care staff members in conducting the fire drills in the proper rotation. 03/22/2023 Implemented
6400.141(a)Annual physical exam for individual #2 was not completed on an annual basis and was completed late: The 7/21/2021 was completed on and next exam was completed until 10/5/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. We have replaced the individua¿s PCP with a new doctor. The individual¿s new primary care physician will see the individual on 08/04/2023. The individual¿s annual exam will be scheduled during this visit. 03/22/2023 Implemented
6400.181(d)Program Specialist did not sign and date the current assessment for individual #2The program specialist shall sign and date the assessment. Program specialists have already signed and dated the individual¿s current assessment. 03/22/2023 Implemented
6400.181(f)There is no documentation that the current assessment for individual #2 was sent to the ISP team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Up to present, we still don¿t have a support coordinator for the individual. Several attempts have been made to request information about the individual supports coordinator but to no avail. 04/20/2023 Implemented
6400.183(c)The record did not indicate if the 2022 ISP meeting was held for individual #2, as there was no sign in sheet for the annual ISP team meeting to include the attendees.The list of persons who participated in the individual plan meeting shall be kept.Up to present, we still don¿t have a support coordinator for the individual. Several attempts have been made to request information about the individual supports coordinator but to no avail. 04/20/2023 Implemented
SIN-00185600 Renewal 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror located in Individual #3 bedroom at time of inspection.In bedrooms, each individual shall have the following: A mirror. Regulation 6400. 81K6: Importance of Regulation o This regulation is critical for ensuring that individuals right to maintain as it relates to Everyday Lives. Regulation Violated o There was no mirror located in Individual #3 bedroom at time of inspection. Fix of Violation. o Staff placed the mirror back in the individual¿s room on 03/29/21. Responsible Person o Summer Kollie is responsible to prevent future violations. o Acute anticipated the resolution of this violation by 4/15/21 o Violation was resolved on 3/29/21 o Based on analysis of other individuals, similar violation occurred at one another home and was corrected (Individual #2). 03/29/2021 Implemented
SIN-00093269 Renewal 04/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15. The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. WHO: Douglas Jones, CEO/Administrator WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15. WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16 HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments. PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter. An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office. ATTACHMENT AND SUPPORTING DOCUMENTS Self-Assessment WHO: Douglas Jones, CEO/Administrator WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15. WHEN: Target Date of completion was 05/04/16. Specific Date of Completion was 05/04/16 HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments. PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter. An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office. ATTACHMENT AND SUPPORTING DOCUMENTS Self-Assessment WHO: Douglas Jones, CEO/Administrator WHAT WILL BE CORRECTED: The self-assessment was not completed 3-6 months prior to license expiration date which is 12/29/15. WHEN: Target Date of completion was 05/07/16. Specific Date of Completion was 05/07/16 HOW: Fix the Violation, an immediate self-assessment for 3320 Mary Street, Apartment 1 Drexel Hill, PA 19026 was conducted on 4/30/2016. A copy of the assessment was placed in a centralize folder hosting all of Acute¿s assessments. PLAN TO PREVENT FUTURE OCCURRENCE: The responsible staff will ensure that Acute completes a self-assessment of each home it operates within 3 to 6 months prior to the expiration date of the certificate of compliance, to measure and record compliance with this chapter. An outlook calendar will be set to alert the CEO 4 months prior to the Certificate of Compliance expiration date. Once the assessment is completed, a copy of the assessment will be stored in the home and in the head office. ATTACHMENT AND SUPPORTING DOCUMENTS Self-Assessment 05/07/2016 Implemented
SIN-00157634 Renewal 06/19/2019 Compliant - Finalized
SIN-00110720 Renewal 04/28/2017 Compliant - Finalized
SIN-00087775 Technical Assistance 12/28/2015 Compliant - Finalized